The arrival sequence was: AMX404 — VRD56 — BWA526 — AAL32 — JBU302. ATC applied positive control on both VRD56 and AAL32, issuing: “…right Juliet, hold short of two-two-right, remain this frequency….” Importantly, this clearance was NOTissued to BWA526. Also, a full five minutes passed between the time ATC issued the ‘hold short 22R’ to VRD56 and then AAL32; thus, the arrival spacing was averaging one per 2.5 minutes, which is a relatively calm arrival rate.

The departure sequence was: JBU1337 — AZA611 — UAE206 — JBU1295. For each departure, ATC had the aircraft ‘line up and wait’ on the runway, then issued a takeoff clearance after the previous arrival had finished taxiing across the runway downfield. Again, at the time the controller cleared JBU1295 for takeoff, he had done nothing to ensure BWA526 would hold short of the same runway.

Additionally, there is no evidence that the controller needed to be in any hurry. AMX404 was crossed prior to takeoff clearance for UAE206 (at time 27:35). Then, it was a full two minutes later, when VRD56 was crossed prior to takeoff clearance for JBU1295 (at time 29:41). And notice on the transcript that, immediately after clearing JBU1295 for takeoff, the controller does NOTfocus on BWA526; instead, he diverts his attention to a nonessential flight, a VFR Cessna overflight whom he tells to maintain at or below just 500-feet altitude under departing jets (an approval that in itself is arguably unsafe).

So, what happened?

This appears to be a classic same-runway controller error, where the controller simply ‘temporarily forgot’ about one of his aircraft. Happens all the time. This is why controllers are trained to scan all the time, and this is also why it is valuable to have more than one controller watching the runway areas. Had this controller been in training, his instructor would have written him up for a ‘POSNI’ (Positive Separation not Insured). Then, again, the instructor’s job is to make sure situations like this never happen, so it might also have been swept under the rug….

Of course, the BWA56 flight crew was a major part of this error, too. Most pilots would have stopped short of the runway and radioed ATC advising they were holding short, and asking for further instructions. But, it is up to the controller to ‘control’ the traffic, by issuing crisp and timely clearances that keep the aircraft flowing and out of trouble. This controller, on this particular Saturday night, was surprisingly sloppy with his phraseology, and it came back to bite him.

It is worth saying again: this sort of incident happens all the time, where a controller temporarily spaces on one aircraft. This latest incident is just the ‘big league’ version of a very similar scenario, the 7/25/2010 Controller Error at KCMA. That, too, was swept under the rug. In fact, the Camarillo controller error was concealed by the tower supervisor, then the tower manager, then the hub management, then the regional QA people, and eventually even by Clay Foushee and Tony Ferrante at FAA Headquarters.

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